Healthcare Provider Details

I. General information

NPI: 1619173812
Provider Name (Legal Business Name): LISA RENEE LASALLE CCC-SLP, BRFS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 09/24/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WARRELMAN CT
MARINA CA
93933-5051
US

IV. Provider business mailing address

525 WARRELMAN CT
MARINA CA
93933-5051
US

V. Phone/Fax

Practice location:
  • Phone: 909-206-3981
  • Fax:
Mailing address:
  • Phone: 909-206-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: